| NPI | 1558856815 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NJ 22DR03255) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NJ 22DI02726900) |
| Enumeration Date | 2018-06-28 |
| Last Update Date | 2019-07-10 |